Improving Maternal Health through Policy Interventions

The long-term goal of the proposed research project is to improve maternal health by reducing severe maternal morbidity and maternal mortality. Specifically, the proposed research project will assess the effectiveness of 3 significant health insurance expansion policies in reducing severe maternal morbidity (SMM) rate: 1) the 2010 Dependent Coverage Provision under the Patient Protection and Affordable Care Act (ACA), requiring private health insurers to allow young adults to remain on their parent’s plan until their 26th birthday; 2) the 2014 ACA Medicaid expansion, giving states the option to expand Medicaid coverage to non-elderly adults with incomes up to 138% of the Federal Poverty Level; and 3) the Maintenance of Effort of the 2020 Families First Coronavirus Response Act (FFCRA) temporarily maintaining Medicaid coverage beyond 60-day postpartum as long as the COVID-19 Public Health Emergency was in place. SMM refers to unintended serious complications of labor and delivery and is associated with substantially increased risk of maternal death. The rate of SMM during childbirth has nearly doubled during the last two decades, increasing from 0.8% in 1999 to 1.8% in 2021. Addressing SMM is recognized as an urgent public health priority. Providing continuous health insurance coverage through health policies, from preconception to 1-year postpartum, is a suggested intervention to mitigate SMM. Up to 80% of pregnant individuals do not have such continuous coverage. However, evidence linking health insurance policy changes to reduced SMM rate is scant. The 2010 ACA Dependent Coverage Provision, the 2014 ACA Medicaid expansion, and the 2020 FFCRA Maintenance of Effort present three natural experiments for assessing the effectiveness of expanding health insurance coverage in reducing SMM. The proposed project will test a series of hypotheses related to the specific aims, including: 1) Expanded access to private health insurance for individuals under age 26 is associated with reduced SMM rate during childbirth; 2) Expanded Medicaid coverage for low-income individuals is associated with reduced SMM rate during childbirth, and 3) Extending Medicaid coverage for low-income individuals from 60-day to 1-year postpartum is associated with decreased SMM rate during the postpartum period. National and state data from the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, will be analyzed using robust quasi-experimental approaches such as the difference-in-difference-in-differences. Results of this project will help close important gaps in maternal health research and provide rigorous evidence to inform policy interventions to reduce the SMM rate. It aligns with the aims of the IMPROVE initiative of the National Institutes of Health.